Posterior plating as an alternative to external fixators in the first stage of treatment of pilon fracture with anteromedial soft tissue injury

Posterior plating as an alternative to external fixators in the first stage of treatment of pilon fracture with anteromedial soft tissue injury | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Posterior plating as an alternative to external fixators in the first stage of treatment of pilon fracture with anteromedial soft tissue injury Amir Sabbaghzadeh, Mona Gorji, Mohammad Sadegh Rezaiyan, Morteza Gholipour, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3309320/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Pilon fractures management is a challenge. Orthopedic surgeons should manage fracture and soft tissue injury simultaneously in optimum condition. This study evaluates the outcomes of the management of Pilon fracture in two different approaches. Materials and methods: 40 patients were included with Pilon fractures Between March 2016 and March 2018. Patients were divided into A and B groups. Group A was operated with the external fixator of the pilon and open reduction and internal fixation (ORIF) of distal fibular in the first stage, and medial plating of the pilon in the second stage. Group B was operated with posterior plating of the pilon and fibular by posterolateral approach at the first stage and medial distal tibia plating in the second stage. The AOFAS score, postoperative satisfaction questionnaire score (MODEMS) score, surgical wound complication, union rate, and operation time were evaluated in 12-month follow-up. Results: 40 Pilon fractures were evaluated finally. 28 were male and 12 were female. Average time for union was 200 ±10 days in group A, and 215±20 days in group B. The average operation duration in the first stage was 65±10 min in group A and 60± 15 min in group B. The MODEMS score at the end of the first stage in most patients of group A was somewhat dissatisfied(86%) and in group B was somewhat satisfied (84%). This score at the end of the 12-month follow-up in most patients of group A and group B was somewhat satisfied, 85% and 87% respectively. The mean AOFAS score in groups A and B were 87.5 and 89.4 respectively at the end of follow-up. There was no significant difference between the two groups in the union rate and time and duration of the operation. Patients in the posterior plating group were more satisfied during the first stage of surgery but in the long-term follow-up, there was no difference between the two groups. Conclusion: Most surgeons prefer the two-stage strategy and external fixator usage at the stage one to manage the soft tissue complications in the pilon fractures . Based on the result, Posterior plating may be a substitute for external fixation in the first stage of Pilon fractures management. Posterior plating external fixators pilon fracture anteromedial soft tissue injury Figures Figure 1 Figure 2 Figure 3 Introduction High-energy trauma can cause Pilon fractures, which present with comminuted intra- extraarticular fractures, or both. Treatment of Pilon fractures is challenging because of various treatment strategies to manage bone and soft tissue injury simultaneously in optimum condition ( 1 ). Viscoelastic prosperity in cancellous bone brings about talus to the Pilon area impaction and furthur Severe soft tissue injury from simple edema and non-hemorrhagic or hemorrhagic blister, to compartment syndrome and open fractures ( 2 ).The goals of therapy are restoring an anatomic articular surface and alignment with rigid fixation in an optimum soft tissue condition.It allows early rehabilitation for obtaining the most beneficial outcome ( 3 ). Most authors define two treatment strategies: 1) Two-stage management which initial external fixation allows soft tissue recovery for two weeks before definitive Pilon operation.. Distal fibula fracture is usually plating in the first stage. This method has less soft tissue complications and compliance, but more duration ( 4 ). 2) One-stage treatment which of all fractures platted during the first 48 hours of trauma, with the anteromedial approach for pilon and the lateral approach for fibular fracture. This method needs an experienced surgeon and has more soft tissue complication and compliance ( 4 ). Sajadi et al. revealed no significant difference in duration of operation, postoperative infection, and AOFAS score between one-stage and two-stage strategies, except that longer hospitalization period for the two-stage treatment ( 5 ). Posterior plating is another approach for the pilon area with limited visualization of the articular surface due to the anatomic feature of the posterior Pilon. so the reduction will be done indirectly ( 5 ). This retrospective cohort compares the outcomes of Pilon fractures in two-stage management with different approaches. External fixation and then the anteromedial approach in the first group; and, posterolateral approach with posterior plating instead of the external fixator and then the anteromedial approach in the second group We suggest that the adverse effect of the external fixator could be avoided and the patient is more satisfied with the posterior plating of pilon fractures in the first stage. Materials and methods 40 patients with Pilon fractures were divided into two groups of surgery (A and B). Patients with type C fractures, open fractures, history of previous leg fractures, diabetic foot, neuromuscular disease, posterior and posterolateral leg blister, skin disease, and age less than 20 years old were excluded. Patients’ information including Age, gender, date of fractures, and medical co-morbidities were collected from electronic medical records. Fracture type was determined based on AO / OTA classification (43).. All cases were evaluated with standard 3-view ankle radiographs (anteroposterior, lateral, and Mortise) and computed tomography (CT) scans with 3-dimensional reconstruction. All patients had severe soft tissue injuries in the anteromedial ankle including hemorrhagic or non-hemorrhagic blisters that were unsuitable for a direct single-stage anteromedial approach (figureA). Patient satisfaction was assessed by The postoperative satisfaction questionnaire score (MODEMS) satisfaction questionnaire score at the end of the first stage and final follow-up surgery. This questionnaire measured pain and overall function in five scales (1 = very dissatisfied, 2 = somewhat dissatisfied, 3 = neutral, 4 = somewhat satisfied, 5 = very satisfied) ( 6 ). AOFAS score were evaluated at the end of the final follow-up in each group. The operation duration of the first stage was assessed in two groups based on operating room documentation ( 7 ). The pin-tract infection complication was assessed by the Checketts-Otterburn classification ( 8 ). Surgical site infection was evaluated clinically by the surgeon ( 9 ). Surgical Protocol All patients had an initial closed reduction in the emergency department with spinal block. After initial splinting, the leg kept elevated to control swelling. In group A an initial Fibular ORIF was performed through a direct lateral approach. Then Delta configuration external fixation was used to restore the primary reduction. The second stage of the operation was performed after soft tissue recovery through the anteromedial approach. (Figure B-a). In group B an initial Fibular ORIF with further posterior pilon plating by Proximal Humerus Internal Locking System (PHILOS ) or T-plate was performed through the direct posterolateral approach (Figure B-b). ligamentotaxis by the guide of C-arm performed the articular surface reduction. and the fracture was fixed by multiple lag screws and plates fixed the fractures. Ultimately, the wounds were managed in both groups with the Algower-Donati suture technique, and Jones's bandages. The second stage was performed after soft tissue recovery through the anteromedial approach. Post-operattive protocol The post-operation protocols were the same for the two groups. Anticoagulants were given to patients according to the national protocol. The short leg splint applied to the ankle in a neutral position and removed 2 to 3 weeks postoperatively. Sutures of the healed woundswere removed. The early Non-weight bearing ankle movment was encouraged after removing the splint until 8 to 10 weeks postoperatively.. Full weight-bearing usually was permitted three months postoperatively, depending on radiographic evidence. Non-union was defined as no evidence of healing after 9 months or lack of union progression after three monthly consecutive graphies ( 10 , 11 ). The patients were examined weekly after the first stage and in the second weeks and thefirst, third, sixth, ninth, and twelfth months after the second stage for surgical complications and union situation. Radiography was taken to check the union and reduction of fixation. Patient data were statistically analyzed to determine the association between variables and complication outcomes. Significance tests were conducted using the t-test for continuous variables and Fischer exact test for categorical variables. All tests were two-tailed with differences reported as significant if p < 0.05. Results 40 patients finally followed up at a mean time of 12 months, with an average age of 35 years old. 13 males and 7 females presented in group A, and 15 males and 5 females presented in group B. The average operation duration was 65 ± 10 min (group A) and 60 ± 15 min (group B). In group A two cases were diagnosed with superficial surgical site infection at the second stage, in the medial plating, treated successfully with antibiotic therapy. Four cases had the pin-tract infection in the first stage. Half of them had minor infections (Chekett Classification Grade 2) that were managed with oral antibiotic therapy; and another half had pin loosening managed pin replacement, intravenous antibiotic therapy, and delayed second stage, In group B three cases were diagnosed with superficial surgical site infection at the second stage in the anteromedial incision, treated successfully with antibiotic therapy. The mean union time was 200 ± 10 days (group A) and 215 ± 20 days (group B). Two cases in group A and three cases in group B didn’t show radiographic union evidence in the sixth postoperative month but all of them had union finally. The postoperative satisfaction questionnaire score (MODEMS) at the end of the first stage in group A was 86% somewhat dissatisfied, 9% very dissatisfied, and 5% neutral. MODEMS at the end of the final follow-up in group A was 85% somewhat satisfied, 10% very satisfied, and 5% neutral.This scale in group B was 84% somewhat satisfied 9% neutral and 7% somewhat dissatisfied at the end of the first stage and 87% somewhat satisfied, 7% very satisfied, and 6% neutral at the final follow-up. Three patients in group B had acceptable reduction after the first stage so they didn’t enter the second stage. (Fig C) The mean AOFAS score in groups A and B were 87.5 and 89.4 respectively at the end of follow-up. Discussion The main finding of this study was the significant difference in patients’ satisfaction between the theposterior plating and the external fixator in the first stage of pilon management without a significant alteration in final complication and outcome. In the management of Pilon fracture, the two-stage strategy, reduces the complications particularly in types C1, C2, and C3, with fracture blisters at soft tissue preparation ( 4 ).The routine method in two-stage surgery is distal fibular plating and the usage of an external fixator at the first stage. \ Jacob et al. reviewed articles to propose a handling algorithm for the pilon fracture management. Accordingly, one-stage surgery was recommended in the A, B & C1 fractures without soft tissue damage; and, two-stage surgery was recommended in the C2 and C3 AO classification types. He also recommended debridding initially in open fractures and deciding on the type of fixation, based on the fracture type 5 days later ( 4 ). Bishoy et al. also noticed the soft tissue condition, mainly reconstruction of the articular surface as the crucial step, to reduce the possibility of long-term complications in the Pilon fractures planning ( 1 ). Pilon fractures with the posterolateral approach evaluated by Mao Feng et al. with23 patients for complications and the quality. The results showed the effectivness of this method in the management of Pilon fractures( 5 ). Another report from Wang Y et. al with the posterior approach reported only two postoperative infections without soft tissue necrosis out of 16 and an average union time of 210 days. Based on the result the posterior approach was a reliable method with low complication in selected patients. ( 6 ). The random division of sample size unlike the previous publications, is the advantage of our study. In group A, difficulty handling the external fixator and problems with blister dressing were the prime concerns. the posterior plating group was more comfortable in short leg splint and wound treatment compared to the external fixator. Pin tract infection delayed performing the second stage in two patients of A group; However, the overall surgical site infection at the end of the second stage operation was the same between the two groups (P-value > 0.05). In group B, posterior plating satisfied patients more during the first stage of surgery, but in the long-term follow-up, there was no difference between the two groups based on MODEMS. ankle range of motion between the first and second stages normalized, which may be a satisfying factor. However final ankle range of motion wasn’t significantly different between the two groups. Articular surface indirect visualization makes the ligamentotaxis the only reduction method. An acceptable reduction was seen with ligamentotaxis in three patients with posterior plating following the first stage; however, it is not statistically significant but may be a chance in the final operation. The necessity of the prone position may cause difficulty in anesthetic management in this approach. AOFAS among the two groups shows no significant differences, which makes the posterior plating method effective as an external fixation method in the outcome of these fractures management. In this retrospective study, there was no significant difference between the two groups union time, complication rate, and AOFAS score comparison. Therefore, in the first stage of pilon fracture management, posterior tibial plating can be an alternate to external fixation based on patient satisfaction. The limitations include unreliable findings due to the sample size selection from one center, which has similarities to the previous limited findings and a small effect on the validity of this study. AO. 43-C complete intra-articular fractures are another limitation as a result of the lower possibility to fix the plate from behind—because it shows the different patterns of the parts—and the lower possibility of ORIF fibular fractures when the soft tissue swelling is severe—only external fixation is required initially, Thusthe indications that all AO 43-C fractures are operated in two different ways can be controversial. A future comparative study with a large number of patients is recommended for better-evaluation of outcomes and complications. Conclusions According to some controversy in the management of pilon fractures (especially in patients with soft tissue injury), most surgeons prefer two-stage surgery for the restoration of soft tissue by an external fixator inthe first stage. This study shows posterior plating may be a substitute for external fixator in the first stage of Pilon fractures management with severe soft tissue problem that is not suitable for one-stage surgery. Declarations Authors' contributions To qualify for authorship, we hereby declare that the authors have made substantial contributions to the intellectual content of the paper. Each author’s specific contribution is as following A.S: offer main title M.G: manuscript writing/editing M.R: prepared figures M.Gh : prepared figures F.A: manuscript writing/editing H.A: manuscript writing/editing F.A Protocol/project development, study design, and manuscript writing/editing All the authors have read and approved the final manuscript. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Ethical Approval Ethical approval and consent to participate This study was approved by ShahidBeheshti University of Medical Sciences’ ethical community with the following code: IR.SBMU.RETECH.REC.1399.1150 Written consent was acquired from the candidates, and they were allowed to leave the study any time that they wanted. Competing interests The authors declare that they have no competing interests . Consent for publication Not applicable Funding No funding Author details Amir Sabbaghzadeh1, Department of Orthopedic and Trauma Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mona Gorji 2, Skin Research Center ,Shahid Beheshti University of Medical Sciences, Tehran, Iran Mohammad Sadegh Rezaiyan1 , Department of Orthopedic and Trauma Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran Morteza Gholipour1, Department of Orthopedic and Trauma Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran Fatemeh abbbasi3 , Mazandaran University of Medical Sciences, Mazandaran, Iran Hanieh Amani4, Mashhad University of Medical Sciences, Mashhad, Iran Farzad Amoozadeh Omrani *1 Department of Orthopedic and Trauma Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran Acknowledgments : We are thankful to our colleagues at the Shahid Beheshti University of Medical Sciences (SBMU). References Saad BN, Yingling JM, Liporace FA, Yoon RS. Pilon fractures: challenges and solutions. Orthop Res reviews. 2019;11:149. He X, Hu Y, Ye P, Huang L, Zhang F, Ruan Y. The operative treatment of complex pilon fractures: a strategy of soft tissue control. Indian J Orthop. 2013;47(5):487. Tomás-Hernández J. High-energy pilon fractures management: State of the art. EFORT open reviews. 2016;1(10):354–61. Jacob N, Amin A, Giotakis N, Narayan B, Nayagam S, Trompeter AJ. Management of high-energy tibial pilon fractures. Strategies in trauma and limb reconstruction. 2015;10(3):137–47. Gao M, Liu N, Cheng Y, Shi W, Yang H. Treatment outcomes of the posterolateral approach of plate fixation for posterior pilon fractures. Experimental and therapeutic medicine. 2019;17(5):4267–72. Zywiel MG, Mahomed A, Gandhi R, Perruccio AV, Mahomed NN. Measuring expectations in orthopaedic surgery: a systematic review. Clin Orthop Relat Research®. 2013;471(11):3446–56. Wu A, Brovman EY, Whang EE, Ehrenfeld JM, Urman RD. The impact of overestimations of surgical control times across multiple specialties on medical systems. J Med Syst. 2016;40(4):95. Checketts R, MacEachem A, Otterbum M. Pin track infection and the principles of pin site care. Orthofix external fixation in trauma and orthopaedics. Springer; 2000. pp. 97–103. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784–91. Ronga M, Longo UG, Maffulli N. Minimally invasive locked plating of distal tibia fractures is safe and effective. Clin Orthop Relat Research®. 2010;468(4):975–82. Bacon S, Smith WR, Morgan SJ, Hasenboehler E, Philips G, Williams A, et al. A retrospective analysis of comminuted intra-articular fractures of the tibial plafond: open reduction and internal fixation versus external Ilizarov fixation. Injury. 2008;39(2):196–202. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3309320","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":241021796,"identity":"98d3be3b-d572-47e6-bf59-fc80e01f5617","order_by":0,"name":"Amir Sabbaghzadeh","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Amir","middleName":"","lastName":"Sabbaghzadeh","suffix":""},{"id":241021797,"identity":"53c678a3-3706-4c83-a6a9-26e77f4198ff","order_by":1,"name":"Mona Gorji","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mona","middleName":"","lastName":"Gorji","suffix":""},{"id":241021798,"identity":"dbac8b99-50f4-4369-b9ea-cf4b3c8e1b84","order_by":2,"name":"Mohammad Sadegh Rezaiyan","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Sadegh","lastName":"Rezaiyan","suffix":""},{"id":241021799,"identity":"7619b4dd-4cf4-4039-8084-b15deee4cc06","order_by":3,"name":"Morteza Gholipour","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Morteza","middleName":"","lastName":"Gholipour","suffix":""},{"id":241021800,"identity":"e17914e9-99ba-4625-8d91-13db6f701128","order_by":4,"name":"Fatemeh abbasi","email":"","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"","lastName":"abbasi","suffix":""},{"id":241021801,"identity":"c2e47248-a25c-4843-807b-0828394d7e69","order_by":5,"name":"hanieh amani","email":"","orcid":"","institution":"mashhad university of medical sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"hanieh","middleName":"","lastName":"amani","suffix":""},{"id":241021802,"identity":"ad4ca127-d389-4439-bd91-c391e25fde6a","order_by":6,"name":"Farzad amoozadeh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYLACxgYGHn72xsYHDAwHiNRysIFBRrLn8GEDkrTYGNxIS5MgSotue/Oxzx932PAY3Mgxq+apuSPHz8D88NENPFrMzhxLnnHwTBqP5Jk3Zrd5jj0zlmxgMzbOwaflRo4xw8G2wzx8x3OAWtgOJ244wMMmTZQWhgM5ZsU8/0jRInAiLY2Zt40YLUC/MJxtA/oFGMiSc/sOG0s2E/LL8ebDDJVtNvagqPzw5tthOX725oeP8WlBAUw8IJKZWOUgwPiDFNWjYBSMglEwYgAAIG9UjQufIxIAAAAASUVORK5CYII=","orcid":"","institution":"Shahid Beheshti University of Medical Science","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Farzad","middleName":"","lastName":"amoozadeh","suffix":""}],"badges":[],"createdAt":"2023-08-30 08:14:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3309320/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3309320/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":44950415,"identity":"f6cf1db2-c3f6-4284-8c22-df893ae4ca4e","added_by":"auto","created_at":"2023-10-19 21:30:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":398582,"visible":true,"origin":"","legend":"\u003cp\u003eFigure A: 40-year-old patient with non-hemorrhagic blisters in the anteromedial and lateral parts of the ankle. It was unsuitable for single-stage surgery with the anteromedial approach for fixation of pilon fracture and anterolateral approach for fibula fracture.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3309320/v1/5467d6cc557bccd49d0c5559.png"},{"id":44950404,"identity":"dd945dea-5d4c-4ad6-963f-0e2a5d1fd5b1","added_by":"auto","created_at":"2023-10-19 21:30:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":628730,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure B-a\u003c/strong\u003e: A 50-year-old man with \u0026nbsp;type B pilon fracture and hemorrhagic blisters in the anteromedial part of the ankle. ORIF of lateral malleolar with plate ( DCP 3.5) and external fixator of Delta for pilon fracture and in the second stage were operated with anatomical plate in the anteromedial approach for pilon fracture.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3309320/v1/f778b98d6ba1b02355c9b066.png"},{"id":44950414,"identity":"9c1c74ca-71f1-48b2-8358-998c17119769","added_by":"auto","created_at":"2023-10-19 21:30:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":745861,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure B-b\u003c/strong\u003e: a 25-year-old woman with type B pilon fracture and hemorrhagic blister in the anteromedial region of the ankle under ORIF of a pilon fracture with philos plate and lateral malleolar with 1.3 tubular plate in the one stage with the posterolateral approach.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3309320/v1/2f857fcd540fbff413b0c528.png"},{"id":60165998,"identity":"d4e0977c-cfe7-4b3b-b6de-e1f41401587e","added_by":"auto","created_at":"2024-07-12 14:14:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1975747,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3309320/v1/2a98bbb7-4b4c-4e83-a701-31801968168b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Posterior plating as an alternative to external fixators in the first stage of treatment of pilon fracture with anteromedial soft tissue injury","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHigh-energy trauma can cause Pilon fractures, which present with comminuted intra- extraarticular fractures, or both. Treatment of Pilon fractures is challenging because of various treatment strategies to manage bone and soft tissue injury simultaneously in optimum condition (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eViscoelastic prosperity in cancellous bone brings about talus to the Pilon area impaction and furthur Severe soft tissue injury from simple edema and non-hemorrhagic or hemorrhagic blister, to compartment syndrome and open fractures (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).The goals of therapy are restoring an anatomic articular surface and alignment with rigid fixation in an optimum soft tissue condition.It allows early rehabilitation for obtaining the most beneficial outcome (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost authors define two treatment strategies:\u003c/p\u003e \u003cp\u003e1) Two-stage management which initial external fixation allows soft tissue recovery for two weeks before definitive Pilon operation.. Distal fibula fracture is usually plating in the first stage. This method has less soft tissue complications and compliance, but more duration (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e2) One-stage treatment which of all fractures platted during the first 48 hours of trauma, with the anteromedial approach for pilon and the lateral approach for fibular fracture. This method needs an experienced surgeon and has more soft tissue complication and compliance (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSajadi et al. revealed no significant difference in duration of operation, postoperative infection, and AOFAS score between one-stage and two-stage strategies, except that longer hospitalization period for the two-stage treatment (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePosterior plating is another approach for the pilon area with limited visualization of the articular surface due to the anatomic feature of the posterior Pilon. so the reduction will be done indirectly (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis retrospective cohort compares the outcomes of Pilon fractures in two-stage management with different approaches. External fixation and then the anteromedial approach in the first group; and, posterolateral approach with posterior plating instead of the external fixator and then the anteromedial approach in the second group We suggest that the adverse effect of the external fixator could be avoided and the patient is more satisfied with the posterior plating of pilon fractures in the first stage.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e40 patients with Pilon fractures were divided into two groups of surgery (A and B). Patients with type C fractures, open fractures, history of previous leg fractures, diabetic foot, neuromuscular disease, posterior and posterolateral leg blister, skin disease, and age less than 20 years old were excluded.\u003c/p\u003e\n\u003cp\u003ePatients\u0026rsquo; information including Age, gender, date of fractures, and medical co-morbidities were collected from electronic medical records. Fracture type was determined based on AO / OTA classification (43).. All cases were evaluated with standard 3-view ankle radiographs (anteroposterior, lateral, and Mortise) and computed tomography (CT) scans with 3-dimensional reconstruction. All patients had severe soft tissue injuries in the anteromedial ankle including hemorrhagic or non-hemorrhagic blisters that were unsuitable for a direct single-stage anteromedial approach (figureA).\u003c/p\u003e\n\u003cp\u003ePatient satisfaction was assessed by The postoperative satisfaction questionnaire score (MODEMS) satisfaction questionnaire score at the end of the first stage and final follow-up surgery. This questionnaire measured pain and overall function in five scales (1\u0026thinsp;=\u0026thinsp;very dissatisfied, 2\u0026thinsp;=\u0026thinsp;somewhat dissatisfied, 3\u0026thinsp;=\u0026thinsp;neutral, 4\u0026thinsp;=\u0026thinsp;somewhat satisfied, 5\u0026thinsp;=\u0026thinsp;very satisfied) (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). AOFAS score were evaluated at the end of the final follow-up in each group. The operation duration of the first stage was assessed in two groups based on operating room documentation (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e). The pin-tract infection complication was assessed by the Checketts-Otterburn classification (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). Surgical site infection was evaluated clinically by the surgeon (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eSurgical Protocol\u003c/h2\u003e\n\u003cp\u003eAll patients had an initial closed reduction in the emergency department with spinal block. After initial splinting, the leg kept elevated to control swelling. In group A an initial Fibular ORIF was performed through a direct lateral approach. Then Delta configuration external fixation was used to restore the primary reduction. The second stage of the operation was performed after soft tissue recovery through the anteromedial approach. (Figure B-a). In group B an initial Fibular ORIF with further posterior pilon plating by Proximal Humerus Internal Locking System (PHILOS ) or T-plate was performed through the direct posterolateral approach (Figure B-b).\u003c/p\u003e\n\u003cp\u003eligamentotaxis by the guide of C-arm performed the articular surface reduction. and the fracture was fixed by multiple lag screws and plates fixed the fractures. Ultimately, the wounds were managed in both groups with the Algower-Donati suture technique, and Jones's bandages. The second stage was performed after soft tissue recovery through the anteromedial approach.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003ePost-operattive protocol\u003c/h2\u003e\n\u003cp\u003eThe post-operation protocols were the same for the two groups. Anticoagulants were given to patients according to the national protocol. The short leg splint applied to the ankle in a neutral position and removed 2 to 3 weeks postoperatively. Sutures of the healed woundswere removed. The early Non-weight bearing ankle movment was encouraged after removing the splint until 8 to 10 weeks postoperatively.. Full weight-bearing usually was permitted three months postoperatively, depending on radiographic evidence. Non-union was defined as no evidence of healing after 9 months or lack of union progression after three monthly consecutive graphies (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). The patients were examined weekly after the first stage and in the second weeks and thefirst, third, sixth, ninth, and twelfth months after the second stage for surgical complications and union situation. Radiography was taken to check the union and reduction of fixation.\u003c/p\u003e\n\u003cp\u003ePatient data were statistically analyzed to determine the association between variables and complication outcomes. Significance tests were conducted using the t-test for continuous variables and Fischer exact test for categorical variables. All tests were two-tailed with differences reported as significant if p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e40 patients finally followed up at a mean time of 12 months, with an average age of 35 years old. 13 males and 7 females presented in group A, and 15 males and 5 females presented in group B. The average operation duration was 65\u0026thinsp;\u0026plusmn;\u0026thinsp;10 min (group A) and 60\u0026thinsp;\u0026plusmn;\u0026thinsp;15 min (group B).\u003c/p\u003e \u003cp\u003eIn group A two cases were diagnosed with superficial surgical site infection at the second stage, in the medial plating, treated successfully with antibiotic therapy. Four cases had the pin-tract infection in the first stage. Half of them had minor infections (Chekett Classification Grade 2) that were managed with oral antibiotic therapy; and another half had pin loosening managed pin replacement, intravenous antibiotic therapy, and delayed second stage,\u003c/p\u003e \u003cp\u003eIn group B three cases were diagnosed with superficial surgical site infection at the second stage in the anteromedial incision, treated successfully with antibiotic therapy.\u003c/p\u003e \u003cp\u003eThe mean union time was 200\u0026thinsp;\u0026plusmn;\u0026thinsp;10 days (group A) and 215\u0026thinsp;\u0026plusmn;\u0026thinsp;20 days (group B). Two cases in group A and three cases in group B didn\u0026rsquo;t show radiographic union evidence in the sixth postoperative month but all of them had union finally.\u003c/p\u003e \u003cp\u003eThe postoperative satisfaction questionnaire score (MODEMS) at the end of the first stage in group A was 86% somewhat dissatisfied, 9% very dissatisfied, and 5% neutral. MODEMS at the end of the final follow-up in group A was 85% somewhat satisfied, 10% very satisfied, and 5% neutral.This scale in group B was 84% somewhat satisfied 9% neutral and 7% somewhat dissatisfied at the end of the first stage and 87% somewhat satisfied, 7% very satisfied, and 6% neutral at the final follow-up.\u003c/p\u003e \u003cp\u003eThree patients in group B had acceptable reduction after the first stage so they didn\u0026rsquo;t enter\u003c/p\u003e \u003cp\u003ethe second stage. (Fig C) The mean AOFAS score in groups A and B were 87.5 and 89.4 respectively at the end of follow-up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main finding of this study was the significant difference in patients\u0026rsquo; satisfaction between the theposterior plating and the external fixator in the first stage of pilon management without a significant alteration in final complication and outcome.\u003c/p\u003e \u003cp\u003eIn the management of Pilon fracture, the two-stage strategy, reduces the complications particularly in types C1, C2, and C3, with fracture blisters at soft tissue preparation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).The routine method in two-stage surgery is distal fibular plating and the usage of an external fixator at the first stage.\u003c/p\u003e \u003cp\u003e\\ Jacob et al. reviewed articles to propose a handling algorithm for the pilon fracture management. Accordingly, one-stage surgery was recommended in the A, B \u0026amp; C1 fractures without soft tissue damage; and, two-stage surgery was recommended in the C2 and C3 AO classification types. He also recommended debridding initially in open fractures and deciding on the type of fixation, based on the fracture type 5 days later (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBishoy et al. also noticed the soft tissue condition, mainly reconstruction of the articular surface as the crucial step, to reduce the possibility of long-term complications in the Pilon fractures planning (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePilon fractures with the posterolateral approach evaluated by Mao Feng et al. with23 patients for complications and the quality. The results showed the effectivness of this method in the management of Pilon fractures(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother report from Wang Y et. al with the posterior approach reported only two postoperative infections without soft tissue necrosis out of 16 and an average union time of 210 days. Based on the result the posterior approach was a reliable method with low complication in selected patients. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe random division of sample size unlike the previous publications, is the advantage of our study.\u003c/p\u003e \u003cp\u003eIn group A, difficulty handling the external fixator and problems with blister dressing were the prime concerns. the posterior plating group was more comfortable in short leg splint and wound treatment compared to the external fixator. Pin tract infection delayed performing the second stage in two patients of A group; However, the overall surgical site infection at the end of the second stage operation was the same between the two groups (P-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In group B, posterior plating satisfied patients more during the first stage of surgery, but in the long-term follow-up, there was no difference between the two groups based on MODEMS. ankle range of motion between the first and second stages normalized, which may be a satisfying factor. However final ankle range of motion wasn\u0026rsquo;t significantly different between the two groups. Articular surface indirect visualization makes the ligamentotaxis the only reduction method. An acceptable reduction was seen with ligamentotaxis in three patients with posterior plating following the first stage; however, it is not statistically significant but may be a chance in the final operation. The necessity of the prone position may cause difficulty in anesthetic management in this approach. AOFAS among the two groups shows no significant differences, which makes the posterior plating method effective as an external fixation method in the outcome of these fractures management.\u003c/p\u003e \u003cp\u003eIn this retrospective study, there was no significant difference between the two groups union time, complication rate, and AOFAS score comparison. Therefore, in the first stage of pilon fracture management, posterior tibial plating can be an alternate to external fixation based on patient satisfaction.\u003c/p\u003e \u003cp\u003eThe limitations include unreliable findings due to the sample size selection from one center, which has similarities to the previous limited findings and a small effect on the validity of this study. AO. 43-C complete intra-articular fractures are another limitation as a result of the lower possibility to fix the plate from behind\u0026mdash;because it shows the different patterns of the parts\u0026mdash;and the lower possibility of ORIF fibular fractures when the soft tissue swelling is severe\u0026mdash;only external fixation is required initially, Thusthe indications that all AO 43-C fractures are operated in two different ways can be controversial.\u003c/p\u003e \u003cp\u003eA future comparative study with a large number of patients is recommended for better-evaluation of outcomes and complications.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAccording to some controversy in the management of pilon fractures (especially in patients with soft tissue injury), most surgeons prefer two-stage surgery for the restoration of soft tissue by an external fixator inthe first stage. This study shows posterior plating may be a substitute for external fixator in the first stage of Pilon fractures management with severe soft tissue problem that is not suitable for one-stage surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo qualify for authorship, we hereby declare that the authors have made substantial contributions to the intellectual content of the paper. Each author\u0026rsquo;s specific contribution is as following\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA.S:\u003c/strong\u003e offer main title\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eM.G:\u0026nbsp;\u003c/strong\u003e manuscript\u0026nbsp;writing/editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eM.R:\u003c/strong\u003e prepared figures\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eM.Gh\u003c/strong\u003e: prepared figures\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF.A:\u003c/strong\u003e manuscript\u0026nbsp;writing/editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eH.A:\u003c/strong\u003e manuscript\u0026nbsp;writing/editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF.A\u003c/strong\u003e Protocol/project development, study\u0026nbsp;design, and manuscript\u0026nbsp;writing/editing\u003c/p\u003e\n\u003cp\u003eAll the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author\u0026nbsp;upon\u0026nbsp;reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e and consent\u0026nbsp;to participate\u003c/p\u003e\n\u003cp\u003eThis study\u0026nbsp;was\u0026nbsp;approved by ShahidBeheshti \u0026nbsp;University of Medical Sciences\u0026rsquo; ethical community with the following code:\u0026nbsp;IR.SBMU.RETECH.REC.1399.1150\u003c/p\u003e\n\u003cp\u003eWritten\u0026nbsp;consent was acquired from\u0026nbsp;the\u0026nbsp;candidates,\u0026nbsp;and they were allowed to leave the study any time that they wanted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmir Sabbaghzadeh1,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopedic and Trauma Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMona Gorji 2,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSkin Research Center ,Shahid Beheshti University of Medical Sciences, Tehran, Iran\u003c/p\u003e\n\u003cp\u003eMohammad Sadegh Rezaiyan1 \u0026nbsp;,\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopedic and Trauma Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMorteza Gholipour1,\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopedic and Trauma Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFatemeh abbbasi3 ,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMazandaran University of Medical Sciences, Mazandaran, Iran\u003c/p\u003e\n\u003cp\u003eHanieh Amani4,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMashhad University of Medical Sciences, Mashhad, Iran\u003c/p\u003e\n\u003cp\u003eFarzad Amoozadeh Omrani *1\u003c/p\u003e\n\u003cp\u003eDepartment of Orthopedic and Trauma Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe are thankful to our colleagues at the Shahid Beheshti University of Medical Sciences (SBMU).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSaad BN, Yingling JM, Liporace FA, Yoon RS. Pilon fractures: challenges and solutions. Orthop Res reviews. 2019;11:149.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe X, Hu Y, Ye P, Huang L, Zhang F, Ruan Y. The operative treatment of complex pilon fractures: a strategy of soft tissue control. Indian J Orthop. 2013;47(5):487.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTom\u0026aacute;s-Hern\u0026aacute;ndez J. High-energy pilon fractures management: State of the art. EFORT open reviews. 2016;1(10):354\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacob N, Amin A, Giotakis N, Narayan B, Nayagam S, Trompeter AJ. Management of high-energy tibial pilon fractures. Strategies in trauma and limb reconstruction. 2015;10(3):137\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao M, Liu N, Cheng Y, Shi W, Yang H. Treatment outcomes of the posterolateral approach of plate fixation for posterior pilon fractures. Experimental and therapeutic medicine. 2019;17(5):4267\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZywiel MG, Mahomed A, Gandhi R, Perruccio AV, Mahomed NN. Measuring expectations in orthopaedic surgery: a systematic review. Clin Orthop Relat Research\u0026reg;. 2013;471(11):3446\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu A, Brovman EY, Whang EE, Ehrenfeld JM, Urman RD. The impact of overestimations of surgical control times across multiple specialties on medical systems. J Med Syst. 2016;40(4):95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChecketts R, MacEachem A, Otterbum M. Pin track infection and the principles of pin site care. Orthofix external fixation in trauma and orthopaedics. Springer; 2000. pp. 97\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerr\u0026iacute;os-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRonga M, Longo UG, Maffulli N. Minimally invasive locked plating of distal tibia fractures is safe and effective. Clin Orthop Relat Research\u0026reg;. 2010;468(4):975\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBacon S, Smith WR, Morgan SJ, Hasenboehler E, Philips G, Williams A, et al. A retrospective analysis of comminuted intra-articular fractures of the tibial plafond: open reduction and internal fixation versus external Ilizarov fixation. Injury. 2008;39(2):196\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Posterior plating, external fixators, pilon fracture, anteromedial soft tissue injury","lastPublishedDoi":"10.21203/rs.3.rs-3309320/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3309320/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Pilon fractures management is a challenge. Orthopedic surgeons should manage fracture and soft tissue injury simultaneously in optimum condition. This study evaluates the outcomes of the management of Pilon fracture in two different approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods:\u003c/strong\u003e 40 patients were included with Pilon fractures Between March 2016 and March 2018. Patients were divided into A and B groups. Group A was operated with the external fixator of the pilon and open reduction and internal fixation (ORIF) of distal fibular in the first stage, and medial plating of the pilon in the second stage. Group B was operated with posterior plating of the pilon and fibular by posterolateral approach at the first stage and medial distal tibia plating in the second stage. The AOFAS score, postoperative satisfaction questionnaire score (MODEMS) \u0026nbsp;score, surgical wound complication, union rate, and operation time were evaluated in 12-month follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 40 Pilon fractures were evaluated finally. 28 were male and 12 were female. Average time for union was 200 ±10 days in group A, and 215±20 days in group B. The average operation duration in the first stage was 65±10 min in group A and 60± 15 min in group B. The MODEMS score at the end of the first stage in most patients of group A was somewhat dissatisfied(86%) and in group B was somewhat satisfied (84%). This score at the end of the 12-month follow-up in most patients of group A and group B was somewhat satisfied, 85% and 87% respectively. The mean AOFAS score in groups A and B were 87.5 and 89.4 respectively at the end of follow-up. There was no significant difference between the two groups in the union rate and time and duration of the operation. Patients in the posterior plating group were more satisfied during the first stage of surgery but in the long-term follow-up, there was no difference between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Most surgeons prefer the two-stage strategy and external fixator usage at the stage one to manage the soft tissue complications in the pilon fractures . Based on the result, Posterior plating may be a substitute for external fixation in the first stage of Pilon fractures management.\u003c/p\u003e","manuscriptTitle":"Posterior plating as an alternative to external fixators in the first stage of treatment of pilon fracture with anteromedial soft tissue injury","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-19 21:30:05","doi":"10.21203/rs.3.rs-3309320/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0768112b-2595-47c1-b3f5-bd31a98cd7d7","owner":[],"postedDate":"October 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-12T14:06:16+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-19 21:30:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3309320","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3309320","identity":"rs-3309320","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}